10 Confabulation: Response to Commentaries John DeLuca, (Newark, NJ)

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Confabulation: Response to Commentaries JohnDeLuca, (Newark, NJ)John DeLuca Ph.D.

a

aNeuropsychology and Neuroscience laboratory, Kessler Medical Rehabilitation, Research

and Education Corporation, 1199 Pleasant Valley Way, West Orange, NJ 07052, e-mail:

Published online: 09 Jan 2014.

To cite this article:John DeLuca Ph.D. (2000) Confabulation: Response to Commentaries John DeLuca, (Newark,NJ), Neuropsychoanalysis: An Interdisciplinary Journal for Psychoanalysis and the Neurosciences, 2:2, 167-170, DOI:

10.1080/15294145.2000.10773302

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Confabulation

Confabulation: Response to Commentaries

John

DeLuca, (Newark, NJ)

I am grateful for the responses to my article on confab

ulation by the commentators. They have all raised very

important and stimulating questions. I am not sure I

can address all of the points made, but I hope to ad

dress the major issues.

In the presentation

of

the psychoanalytic perspec

tive on confabulation, MarkSolmsprovides an intrigu

ing argument for viewing confabulation within the

framework

of

psychoanalytic theory. I was particularly

intrigued with the apparent overlap in constructs be

tween the four characteristics of

the system uncon

scious and some

of

the constructs in neuropsychology

and cognitive neuroscience, to describe confabulation.

The characteristic of tolerance of mutual contradic

tion, whereby two incompatible ideas can exist side

by side, can be analogous to neuropsychological con

cepts

of

unawareness or impaired self-monitoring

found under the rubric

of

executive functions. Time

lessness, where mental contents are not coded in chro

nological sequence, is very similar to the temporal

order difficulties observed in ACoA confabulators.

Replacement of external reality by psychical reality,

where subjective mental contents predominate over

objectively derived (or reality-based) contents, in

some way is related to Weinstein s notion that the

content of confabulation has a psychic , basis

(Weinstein and Kahn, 1955; Weinstein and Lyerly,

1968). Primary process, where the activation of ideas

is unconstrained by external processes to allow for the

expression of inner needs and desires, in some broader

sense can be analogous to the issues of self-monitoring

in executive control systems in the brain. Dr. Solms s

examples of the first two characteristics were very in

teresting and provocative. In the discussion of the third

and fourth unconscious characteristics, the notion of

wishes driving the content of confabulation seems

more challenging to ascribe to all

of

the confabulations

a person may make. What Dr. Solms refers to as

wishful has the feeling of being intentional, al

though presumably at the unconscious level. Dr. Ners

essian refers to this as the patient having a motive

behind their distortion and that the motive stems from

Dr. DeLuca is Professor, Department of Physical Medicine and Reha

bilitation, Department of Neurosciences, UMDNJ-New Jersey Medical

School, Newark, NJ.

7

the requirement of the mental apparatus to decrease

unpleasure and optimize pleasure. Using this logic,

it would be challenging to argue that a person with

left hemispatial neglect and hemiplegia confabu

lates about being able to use the paretic limb because

of a wish to use the left side, although Kinsbourne

proposes this very argument. How can this be verified

(see below)? Also, in the examples provided by Dr.

Solms (e.g., the No Smoking sign; husband in the next

bed), one could argue that these are simply persevera

tive thoughts by the patient, for which the patient is

unable to self-monitor the apparently illogical think

ing. Perhaps this can simply be viewed

as

a difficulty

in the conscious monitoring of the patient s verbal out

put. However, the psychoanalytic view does provide a

potential mechanism (perhaps too psychic for some

neuroscientists). Nonetheless, the psychoanalytic in

terpretation is a viable alternative hypothesis that

needs to be verified.

Dr. Solms suggests that the type of amnesia [I

describe] could itself be described as an executive

disorder. He suggests that the memory disorder I de

scribe

is an executive disorder. Canestri appears to

support Solms s position on this as well. I would agree

that the notion of impaired strategic retrieval, which

monitors the output from the memory system, is in

deed an executive process. However, the declarative

memory disorder itself is not an executive process.

The available evidence (see DeLuca and Diamond,

1995) shows that damage to both the basal forebrain

and

frontal/executive systems is necessary for confab

ulation to be observed in anterior communicating ar

tery (ACoA) patients. The basal forebrain region,

which presumably is responsible for the amnesia in

ACoA patients, is not part of the ventromedial system,

but the declarative memory system. If Solms s notion

were true, then when ACoA patients stop confabulat

ing, they should no longer be amnesic: this does not

occur. The amnesia remains in ACoA patients while

confabulation dissipates, arguing for two separate sys

tems. Other evidence for separate systems include the

fact that patients with executive lesions alone tend not

to confabulate, and that amnesics without executive

impairments themselves do not confabulate. I would

agree that a special type

of executive disorder is

required, but I add that this alone is not sufficient to


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168

produce memory confabulation. I also agree with Dr.

Solms that the ventromedial portions of the frontal

lobes (distribution of the anterior cerebral artery) play

a critical role in memory confabulation, and eagerly

await research studies that support his suggestion that

this area subserve(s functions that are prerequisite

for the secondary process mode of functioning that

characterizes the system Pcs.-Cs.

Dr. Solms succeeds in providing a new, in

sightful, and different perspective on the content

of

confabulation based on a psychoanalytic perspec

tive. The overlap between some of the constructs be

tween the psychoanalytic and cognitive neuroscience

viewpoints

is

intriguing. The difference in approach

perhaps lies in whether a system unconscious is

even required (from the neuroscience perspective) for

an understanding of the content

of

confabulation,

compared to a model that suggests difficulty in the

executive monitoring

of

the outflow

of

conscious in

formation. Cognitive neuroscience appears to prefer

to use the term un w reness or nosognosi when

discussing aspects that do not reach consciousness, but

can both camps really be speaking about the same

thing? Both perspectives are viable approaches to the

problem of confabulation. Ultimately, perhaps the two

perspectives will be able to fuse into a single mech

anism.

Dr. Nersessian presents an interesting perspective

on memory in general. It is well known that recall

from stored memory is a reconstructive process, in

fluenced by many factors (e.g., initial learning context,

postlearning experiences, etc.). That memory recall

can be influenced by

some

real events, some fanta

sies, and some elements

of

a possibly traumatic

event

to create [or reconstruct] a memory

is

consistent with current cognitive neuroscience views

of

memory functioning. Perhaps learning more about

how subjective experience can influence the memory

reconstruction process may be an area where psycho

analytic theories can be tested using cognitive neuro

science techniques.

Dr. Nersessian asks: [O]nce patients are no

longer confabulating, are they capable

of

remember

ing the events occurring at the time

of

their illness

which they could not remember while still confabulat

ing?

This is a very good question. But the answer

is

likely to be very complicated. First, there is some

evidence that problems in retrograde amnesia diminish

with improvements in executive functioning (D Es

posito, Alexander, Fischer, McGlinchey-Berroth, and

O Conner, 1996). It is also well established that con

fabulation diminishes with improvements in executive

John

DeLuca

functions (see DeLuca and Diamond, 1995, for a re

view). So the answer to the question posed may be

tied to some resolution of retrograde recall. But other

variables may also

playa

significant role; for example,

cognitive and personality factors outlined by Johnson,

or affective and psychic factors discussed by Kins

bourne. The second issue regards what such patients

are actually recalling when asked about events that

took place around the time of their illness. Assuming

one finds increased recall following the resolution of

confabulation, are patients now recalling the events

that were previously unavailable or are they recalling

information newly learned about the time

of

the illness

by persons (e.g., family members) providing such in

formation after the patient has recovered? Such fac

tors would have to be controlled to truly answer this

interesting question.

When I read the excellent commentary by

Blechner, it reinforces my decision to exclude from

my discussion confabulation from psychiatric condi

tions. While schizophrenic patients indeed confabu

late, I would argue that the nature

of

the

confabulations differ from say ACoA or Korsakoff

patients. Nathaniel-James and Frith (1996) appear to

agree with this:

The

confabulations elicited appear

to be

of

a new type, which is qualitatively different

from the confabulations observed in Korsakoff s and

Amnesic patients (p. 397). The qualitative differ

ences appear to be the psychotic features associated

with the confabulation

of

schizophrenic patients (e.g.,

hallucinations, voices providing instructions, etc.)

While confabulation following ACoA aneurysm can

appear

iz rre

(a term which provides little behavioral

specificity and should not be used), I have yet to expe

rience an ACoA patient with such psychotic confabu

lations (e.g., Marilyn Monroe was my mother).

Nonetheless, an ultimate explanation of confabulation

broadly defined will have to take into account such

psychotic confabulation.

Envisioning dreams as confabulation is very in

triguing, and easily fits many definitions

of

confabula

tion. However, Blechner provides some characteristics

of

dreams that do not appear in memory confabulation

(e.g., interobjects ). While neologisms are not ob

served in ACoA patients, they do occur in persons

with Wernicke s aphasia, which may be related to the

violation

of

Category Boundaries that Blechner de

scribes. Blechner presents the concept of disjunctive

cognitions, described as the disjunction between ap

pearances and identity within dreams. He presents

neuropsychological evidence for the separation

of

pro

cessing, such as prosopagnosia, and apgrass syn-


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Confabulation

drome (also known as reduplicative paramnesia). The

separation of feature perception and facial identity

recognition brings tomind (and ismentioned byKins

bourne) the work in cognitive neuroscience by Mish

kin and many others who talk about the distinction

of

the dorsal stream and ventral stream in visual

perception (in both humans and primates) (Mishkin,

Ungerleider, and Macko, 1983). The former has been

described as the occipitoparietal perceptual system,

which processes spatial information, while the latter

is an occipitotemporal perceptual system involved in

the processing of object characteristics. Can there be

some overlap between these psychoanalytic and neu

roscientific constructs? In addition to the disjunctive

cognitions, , the distortion of time within dreams

overlaps markedly with that observed in memory con

fabulation.

Kinsbourne directly addresses some key ques

tions regarding the nature of confabulation. While he

states that confabulation comes and goes, memory

confabulation (at least in ACoA patients) comes then

goes. That is, confabulation usually appears (in vari

ous degrees of severity) and usually wanes after weeks

or months. But the question

of

why do even severely

affected patients not confabulate during much or all

deliberate activity is a very good question. (It

should be mentioned that it appears from his examples

that Kinsbourne is talking about broad-sense confabu

lation.)

Dr. Kinsbourne argues that affective significance

of the topic of confabulation is a key to answering

this question. I think this is a fascinating possibility.

However, one is of course immediately tempted to

ask, where is the data? I have yet to see well-designed

studies showing confabulated items as being those that

are more affectively significant versus those which are

not. There are certainly post hoc suggestions (e.g.,

Weinstein and Lyerly, 1968) but no systematic, scien

tific investigation. It sounds as if it has potential as

a great collaborative project for neuroscientists and

psychoanalysts. Although the role of affective coding

in memory processing is well documented, its role in

confabulation remains to be systematically evaluated.

Kinsbourne asks,

What

is it about the combina

tion of poor memory and ventromedial frontal impair

ment that evokes voiced or acted out wish

fulfillment? He suggests that faulty self-monitoring

is not sufficient. However, his notion

of

an inner

directed focus on an affectively laden issue seems to

me equally insufficient, for perhaps the same reasons.

While several commentators have pointed to the ven

tromedial frontal lobes as perhaps involved in

bind

9

in of

wish fulfillment, these remain hypotheses in

need

of

verification and testing.

But what of the confabulating patient who pres

ents inconsistent or opposite positions within the same

session (which is not infrequent)? For instance, after

I asked a recent ACoA patient about the scar on his

head (from the surgery), the patient soon thereafter

reported that his mother recently had an aneurysm and

a scar on her head. Later in the same session, I re

turned to this issue and he denied that his mother had

any medical problems, and explicitly denied that his

mother had an aneurysm or a head scar when I asked

him directly. Perhaps the initial response by this

ACoA patient was nothing more than a perseverative

response to my initially explaining to him that his scar

was a result of surgery for his cerebral aneurysm. I

would have expected an affectively driven hypothesis

to have yielded a consistent confabulat ion in such a

case. However, inconsistency is fairly consistent

among ACoA confabulators.

Johnson provides a very informative, thoughtful,

and thought-provoking discussion on several topics re

lated to confabulation. One very interesting idea is

her suggestion that narrow-sense confabulators (e.g.,

patients with bilateral occipital lesions) be asked ques

tions that have traditionally been reserved for other

narrow-sense confabulators (e.g., frontal/basal fore

brain lesioned patients). This novel idea exposes the

lack

of

standardization of assessment

of

confabulation

and lack

of

cross-talk among researchers and clini

cians studying confabulation from their own patient

populations. I agree with Johnson that we need to

learn more about confusional states and confabulatory

experiences, not only in neuroanatomical terms, but

also in the content of confabulation. Delusions and

hallucinations mayor may not involve similar cogni

tive mechanisms as suggested by Johnson, but this

remains an area

of speculation that again could be a

fruitful area of collaboration between the psychoana

lyst and neuroscientist.

I concur with Johnson (also alluded to by Graff

Radford) that no single structure in the brain will ulti

mately be found to cause confabulation. The distrib

uted nature

of brain functioning continues to be

demonstrated with functional neuroimaging tech

niques. Anterior cerebral structures (e.g., ventromedial

frontal regions, anterior cingulate) are sure to play a

critical role in memory confabulation. Her detailed

analysis from the cognitive psychology literature on

the multiple cognitive, personality, and emotional

variables that contribute to memory distortions and

beliefs provides an excellent springboard from which


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7

collaborative ideas can be applied to the study of con

fabulation. Yet, as Johnson states,

the relations be

tween cognitive and neural mechanisms largely

remain to be specified. I look forward to seeing func

tional neuroimaging techniques applied to confabula

tion, with neuroscientists and psychoanalysts working

in concert.

At this point, I would like to return to the example

of

the irresolvable conflict raised by Kinsbourne

of

the patient with left hemispatial hemiplegia, neglect,

and anosognosia, who denies problems with his left

side. Kinsbourne states that the confabulation is a

psychodynamic reaction to an organic problem.' ,

Johnson attempts to interweave the work from cogni

tive psychology and psychoanalysis by suggesting that

reflection (the 'secondary process') involves an ac

tive inhibitory process by which instructive actions are

inhibited (or delayed), giving thought (other reflective

processes) a chance to have its influence. She sug

gests that active inhibitory processes or active

goals or agendas that activate

bias )

representa

tions or action plans can circumvent instinctive, or

habitual, or prepotent responses. With these points

in mind, perhaps one can ask the following: does the

right parietal lesion resulting in hemispatial neglect

and hemiplegia somehow inhibit (or disinhibit) the

instinctive monitoring (by the right hemisphere)

of

the Interpreter (Gazzaniga, 1998) within the left

hemisphere? Recall that the role

of

the Interpreter is

to interpret information both internally and externally

to logically explain the events in the environment. Per

haps it is this lack of access to the Interpreter that

results in the confabulations observed in such patients.

It seems to me that the investigation of such neuro

scientific hypotheses may have significant implica

tions for psychodynamic constructs and principles.

In closing, I have found these commentaries en

joyable, enlightening, as well

as

intellectually stimu

lating. Ultimately, an all-encompassing model

of

confabulation will need to explain confabulation from

brain damage, psychiatric conditions, and healthy in

dividuals (e.g., dreams, false memories). In agreement

with Dr. Johnson, the only way to accomplish this

John DeLuca

ultimate goal is for research and theory from among

the disciplines

of

cognitive psychology, neuropsychol

ogy, cognitive neuroscience, and psychoanalysis to

come together in a convergence of investigation. Such

a wide gaze as Blechner refers to it, can only be

achieved with such convergence. It is within this spirit

that I proposed a model of broad- and narrow-sense

confabulation. For those of us who cast a narrow

net, there is much to learn from the other disciplines.

But the widest gaze can only be achieved with

work across disciplines. I hope that the discussion pro

vided in this issue will contribute to reaching such a

convergence of investigation on confabulation.

References

DeLuca, J., Diamond,

J

(1995), Aneurysm

of

the

anterior communicating artery: A review of neuroana

tomical and neuropsychological sequelae.

Clin. Exper

iment. Neuropsychol.

17:100-121.

D'Esposito, M., Alexander,

M

P., Fischer, R., McGlinchey

Berroth, R., O'Conner,

M

(1996), Recovery of mem

ory and executive function following anterior communi

cating artery aneurysm rupture. Internat.

Neuropsychol. Soc. 2 6 :565-570.

Gazzaniga, M S (1998), The Mind s Past. Berkeley: Uni

versity of California Press.

Mishkin, M., Ungerleider, L., Macko, K (1983), Object

vision and spatial vision: Two cortical pathways. Trends

in Neurosci.

6 : 4 ~ 7

Nathaniel-James, D A.,

Frith, C D. (1996), Confabula

tion in schizophrenia: Evidence of a new form. Psy

cholog. Med.

26:391-399.

Weins te in, E. A., Kahn, R. L. (1955) , Denial

of

Illness.

Springfield, IL: Charles C Thomas.

Lyerly, O. G (1968), Confabulation following

brain injury: Its analogues and sequelae. Arch. Gen. Psy

chiatry 18:348-354.

John DeLuca Ph.D.

Neuropsychology and Neuroscience Laboratory

Kessler Medical Rehabilitation

Research and Education Corporation

1199 Pleasant Valley

Way

West Orange 07052

e-mail: delucaj. @umdnj.edu

10 Confabulation: Response to Commentaries John DeLuca, (Newark, NJ)

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